Wednesday, January 15, 2014
The first arm of the APPLES study, a prospective parallel group study to evaluate outcomes in a publicly funded population based bariatric program, now published by Raj Padwal and colleagues in Medical Care, looked at weight and health indicators in wait-listed patients.
When APPLES study was initiated in 2008, approximately 1,500 adults were wait-listed for clinic entry with an average wait time of two years.
To get on the waiting list, eligible patients (BMI greater than 35) had to be referred to the bariatric centre by their primary medical practitioner through a central referral service.
Wait-listed patients were advised to attend communitybased group education sessions before clinic entry but otherwise received no specific intervention.
During the 24 months of the APPLES study, structural changes to the program and increased clinic capacity resulted in a shortening of waiting times.
Thus, out of the 150 participants enrolled into the wait-list group, 93 (62%) were seen in the clinic before the end of the 24-month study period. Another 18 (12%) wait-listed subjects dropped out of the study. As a result, complete 24-month follow-up data was only available for 38 (26%) of individuals in this arm of the study.
At 24 months (using a last-observation-carried-forward (LOCF) approach for individuals who dropped out or were no longer on the waiting list), the absolute and relative (% of baseline) mean weight losses were 1.5 kg (0.9%) in the wait-listed group.
While this may seem modest, about one in six participants (17%) achieved a 5% weight-loss, while one in ten (9%) achieved a 10% weight loss at 24 months (or at the time of attrition).
Conversely, about one in eight (13%) of wait-listed participants gained more than 5% during their time on the waiting list.
No significant overall changes in health status were noted during this time.
Thus, this arm of the APPLES study provides some very important insights into what happens to bariatric patients on waiting lists (with the important caveat that waiting times were considerably less than the 24 months anticipated at the commencement of the study).
1) The vast majority of wait-listed patients are weight stable.
2) A roughly equal number of wait-listed patients will experience a clinically significant (5%) weight loss or weight gain (17 vs 13%).
3) During this 1.5 to 2 year waiting period, the overall burden of cardiovascular disease remains about the same.
While health system experts and policy makers may well see this outcome as support for the notion that a 12 or even 24 month waiting time to receive tertiary care bariatric services may well be justifiable, it is important to note that this may be viewed very differently by the folks actually on the waiting list.
I have previously posted insights into how patients in the APPLES study felt about their time on the waiting list.
The majority of subjects expressed concern over wait times (65%) and felt that waiting was very stressful (53%) and physically, emotionally and mentally taxing (62%).
According to the wait-list impact questionnaire, 47% of subjects agreed or strongly agreed that waiting affected their quality of life, 65% described wait times as ‘concerning’ and 81% as ‘frustrating’, 73% worried about the consequences of extended wait times on their health, 68% were frustrated with the allocation of resources and 59% felt that they should not have to wait for obesity treatment.
Surprisingly, however, only 31% were dissatisfied/very dissatisfied with their overall medical care.
This is in line with finding in wait listed bariatric patients in other parts of Canada.
It appears that bariatric patients are overall a very patient and “accepting” crowd – or perhaps just very “Canadian”.
Padwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423